=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275989287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNOTATA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2016
-----------------------------------------------------
Last Update Date | 05/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6300 E INDEPENDENCE BLVD SUITE B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28212-6944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-430-1782
-----------------------------------------------------
Fax | 980-498-0690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 E INDEPENDENCE BLVD SUITE B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28212-6944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-430-1782
-----------------------------------------------------
Fax | 980-498-0690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | LISA BOETTNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-351-9599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 12949
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------